Development, Evaluation and Implementation of Chief Complaint Groupings to Activate Data Collection: A Multi-Center Study of Clinical Decision Support for Children with Head Trauma

BACKGROUND

Overuse of cranial computed tomography scans in children with blunt head trauma unnecessarily exposes them to radiation. The Pediatric Emergency Care Applied Research Network (PECARN) blunt head trauma prediction rules identify children who do not require a computed tomography scan. Electronic health record (EHR) based clinical decision support (CDS) may effectively implement these rules but must only be provided for appropriate patients in order to minimize excessive alerts.

OBJECTIVES

To develop, implement and evaluate site-specific groupings of chief complaints (CC) that accurately identify children with head trauma, in order to activate data collection in an EHR.

METHODS

As part of a 13 site clinical trial comparing cranial computed tomography use before and after implementation of CDS, four PECARN sites centrally developed and locally implemented CC groupings to trigger a clinical trial alert (CTA) to facilitate the completion of an emergency department head trauma data collection template. We tested and chose CC groupings to attain high sensitivity while maintaining at least moderate specificity.

RESULTS

Due to variability in CCs available, identical groupings across sites were not possible. We noted substantial variability in the sensitivity and specificity of seemingly similar CC groupings between sites. The implemented CC groupings had sensitivities greater than 90% with specificities between 75-89%. During the trial, formal testing and provider feedback led to tailoring of the CC groupings at some sites.

CONCLUSIONS

CC groupings can be successfully developed and implemented across multiple sites to accurately identify patients who should have a CTA triggered to facilitate EHR data collection. However, CC groupings will necessarily vary in order to attain high sensitivity and moderate-to-high specificity. In future trials, the balance between sensitivity and specificity should be considered based on the nature of the clinical condition, including prevalence and morbidity, in addition to the goals of the intervention being considered.

Progressive decrease in N-acetylaspartate/Creatine ratio in a teenager with type 1 diabetes and repeated episodes of ketoacidosis without clinically apparent cerebral edema: Evidence for permanent brain injury

Recent data suggest that DKA may contribute to cognitive impairment in children with type 1 DM. We measured the NAA/Cr ratio in a teenager during and following 2 separate episodes of DKA without clinically apparent cerebral edema. The NAA/Cr ratio decreased during DKA and improved following recovery. However, the NAA/Cr value was lower after the second episode of DKA (1.76) than after the first (1.97). These findings provide support for the hypothesis that neuronal injury may result from DKA.

Cerebral proton magnetic resonance spectroscopy in children with diabetic ketoacidosis

BACKGROUND AND PURPOSE

Subclinical cerebral edema occurs in many, if not most, children with diabetic ketoacidosis (DKA) and may be an indicator of subtle brain injury. Brain ratios of N-acetylaspartate (NAA) to creatine (Cr), measured by proton MR spectroscopy, decrease with neuronal injury or dysfunction. We hypothesized that brain NAA/Cr ratios may be decreased in children in DKA, indicating subtle neuronal injury.

MATERIALS AND METHODS

Twenty-nine children with DKA underwent cerebral proton MR spectroscopy during DKA treatment (2-12 hours after initiating therapy) and after recovery from the episode (72 hours or more after the initiation of therapy). We measured peak heights of NAA, Cr, and choline (Cho) in 3 locations within the brain: the occipital gray matter, the basal ganglia, and periaqueductal gray matter. These regions were identified in previous studies as areas at greater risk for neurologic injury in DKA-related cerebral edema. We calculated the ratios of NAA/Cr and Cho/Cr and compared these ratios during the acute illness and recovery periods.

RESULTS

In the basal ganglia, the ratio of NAA/Cr was significantly lower during DKA treatment compared with that after recovery (1.68 +/- 0.24 versus 1.86 +/- 0.28, P<.005). There was a trend toward lower NAA/Cr ratios during DKA treatment in the periaqueductal gray matter (1.66 +/- 0.38 versus 1.91 +/- 0.50, P=.06) and the occipital gray matter (1.97 +/- 0.28 versus 2.13 +/- 0.18, P=.08). In contrast, there were no significant changes in Cho/Cr ratios in any region.

CONCLUSIONS

NAA/Cr ratios are decreased in children during DKA and improve after recovery. This finding suggests that during DKA neuronal function or viability or both are compromised and improve after treatment and recovery.

Coagulation testing in pediatric blunt trauma patients

OBJECTIVES

To determine the prevalence of abnormal coagulation studies and to identify variables associated with markedly elevated coagulation studies in children with blunt trauma.

METHODS

We reviewed the medical records of all patients < 15 years old hospitalized at a Level 1 trauma center for either blunt head or torso trauma over a 4-year period. Data from each patient's emergency department (ED) presentation were abstracted. ED coagulation studies were defined prior to data analysis as elevated if the international normalized ratio (INR) was > or =1.2 or partial thromboplastin time (PTT) was > or =33.0 seconds and markedly elevated if the INR was > or =1.5 or PTT was > or =40 seconds. Variables associated with markedly elevated coagulation studies in a univariate analysis (P < 0.05) were entered into a backward elimination logistic regression analysis to identify variables independently associated with markedly elevated coagulation studies.

RESULTS

A total of 1082 patients' records were reviewed, and the 830 (77%) patients with coagulation studies obtained composed the study population. Elevated coagulation studies were detected in 232 (28%) patients, and 49 (6%) of these were found to be markedly elevated. In the multivariate analysis, a GCS < or =13 (odds ratio [OR] 8.7, 95% confidence interval [CI] 4.3, 17.7), low systolic blood pressure (OR 4.0, 95% CI 1.6, 9.9), open/multiple bony fractures (OR 2.9, 95% CI 1.4, 6.2), and major tissue wounds (OR 2.8, 95% CI 1.4, 5.6) were independently associated with markedly elevated coagulation studies.

CONCLUSION

Hospitalized pediatric blunt trauma patients frequently have minor elevations in ED coagulation studies. Marked elevations occur infrequently and are independently associated with a GCS < or =13, low systolic blood pressure, open/multiple bony fractures, and major tissue wounds.

Emergency department ultrasonography in the evaluation of hypotensive and normotensive children with blunt abdominal trauma

PURPOSE

The aim of this study was to evaluate the accuracy of emergency department (ED) ultrasound scan in identifying which children with blunt torso trauma have intraperitoneal fluid associated with intraabdominal injuries (IAI).

METHODS

The authors conducted a prospective, observational study of children (< 16 years old) with blunt trauma who presented to a level 1 trauma center over a 29-month period and underwent abdominal ultrasound scan while in the ED. Ultrasound examinations were ordered at the discretion of the trauma surgeons or ED physicians caring for the patients, performed by trained sonographers, and interpreted at the time of the ultrasound. Ultrasound examinations were interpreted solely for the presence or absence of intraperitoneal fluid. Hypotension was defined as > or = 1 standard deviation below the age-adjusted mean. Patients underwent follow-up to identify those with intraperitoneal fluid and IAI.

RESULTS

A total of 224 pediatric blunt trauma patients had ultrasound scan performed and were enrolled. Thirty-three patients had IAI with intraperitoneal fluid, and ultrasound scan was positive in 27. The accuracy of abdominal ultrasound for detecting intraperitoneal fluid associated with IAI was sensitivity, 82% (95% confidence interval [CI] 65% to 93%); specificity, 95% (95% CI 91% to 97%); positive predictive value, 73% (95% CI 56% to 86%); and negative predictive value, 97% (95% CI 93% to 99%). In the 13 patients who were hypotensive, ultrasound scan correctly identified intraperitoneal fluid in all 7 patients (sensitivity 100%) with IAI, and hemoperitoneum and was negative in all 6 patients (specificity 100%) who did not have hemoperitoneum. Nine patients had IAI without intraperitoneal fluid, and ultrasound scan result was negative for fluid in all 9.

CONCLUSIONS

ED abdominal ultrasound scan used solely for the detection of intraperitoneal fluid in pediatric blunt trauma patients has a modest accuracy. Ultrasonography has the best test performance in those children who are hypotensive and should be obtained early in the ED evaluation of these patients.

Meningococcal disease among children who live in a large metropolitan area, 1981-1996

Neisseria meningitidis is an important cause of serious bacterial infections in children. We undertook a study to identify meningococcal infections of the blood, cerebrospinal fluid, or both of children in a defined geographic area to describe the burden of disease and the spectrum of illness. We reviewed the medical records of all children aged <18 years who had meningococcal infections at the 4 pediatric referral hospitals in Boston, Massachusetts, from 1981 through 1996. We identified 231 patients with meningococcal disease; of these 231 patients, 194 (84%) had overt disease and 37 (16%) had unsuspected disease. Clinical manifestations included meningitis in 150 patients, hypotension in 26, and purpura in 17. Sixteen patients (7%) died. Although meningococcal disease is devastating to a small number of children, we found that the burden of pediatric disease that it caused at the 4 pediatric referral centers in this geographic region was limited; that patients with overt meningococcal disease are most likely to have meningitis; and that individual practitioners are unlikely to encounter a patient with unsuspected meningococcal disease.

Prevalence and importance of pneumothoraces visualized on abdominal computed tomographic scan in children with blunt trauma

BACKGROUND

Chest radiographs are routinely obtained for the identification of pneumothoraces in trauma patients. Computed tomographic (CT) scanning has a higher sensitivity for the detection of pneumothoraces, but the prevalence and importance of pneumothoraces detectable by CT scan but not by chest radiography in children sustaining blunt trauma is unclear.

METHODS

We conducted a prospective observational cohort study of children less than 16 years old with blunt trauma undergoing both abdominal CT scan and chest radiography in the emergency department of a Level I trauma center over a 28-month period. All abdominal CT scans were interpreted by a single faculty radiologist. The chest radiographs of all patients with pneumothoraces detected on CT scan as well as a random sample of chest radiographs from pediatric blunt trauma patients without pneumothoraces on abdominal CT scan (in a ratio of four normals per pneumothorax) were reviewed by a second faculty radiologist. Both radiologists were masked to all clinical data as well as to the objective of the study.

RESULTS

Five hundred thirty-eight children underwent both abdominal CT scan and chest radiography in the emergency department. Twenty patients (3.7%; 95% confidence interval [CI], 2.3-5.7%) were found to have pneumothoraces on CT scan. Of these 20 patients, 9 (45%; 95% CI, 23-68%) had pneumothoraces identified on initial chest radiography and 11 patients did not ("unsuspected pneumothoraces"). Twelve pneumothoraces were identified in these 11 patients; 6 were graded as minuscule and 6 as anterior according to a previously established scale. One patient with an unsuspected pneumothorax underwent tube thoracostomy. None of the 10 patients (0%; 95% CI, 0-26%) with unsuspected pneumothoraces who were managed without thoracostomy (including two patients who underwent positive pressure ventilation) had complications from their pneumothoraces.

CONCLUSION

Less than half of pediatric blunt trauma patients with pneumothoraces visualized on abdominal CT scan had these pneumothoraces identified on initial chest radiograph. Patients with pneumothoraces identified solely on abdominal CT scan, however, uncommonly require tube thoracostomy.

Risk factors for cerebral edema in children with diabetic ketoacidosis. The Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics

BACKGROUND

Cerebral edema is an uncommon but devastating complication of diabetic ketoacidosis in children. Risk factors for this complication have not been clearly defined.

METHODS

In this multicenter study, we identified 61 children who had been hospitalized for diabetic ketoacidosis within a 15-year period and in whom cerebral edema had developed. Two additional groups of children with diabetic ketoacidosis but without cerebral edema were also identified: 181 randomly selected children and 174 children matched to those in the cerebral-edema group with respect to age at presentation, onset of diabetes (established vs. newly diagnosed disease), initial serum glucose concentration, and initial venous pH. Using logistic regression we compared the three groups with respect to demographic characteristics and biochemical variables at presentation and compared the matched groups with respect to therapeutic interventions and changes in biochemical values during treatment.

RESULTS

A comparison of the children in the cerebral-edema group with those in the random control group showed that cerebral edema was significantly associated with lower initial partial pressures of arterial carbon dioxide (relative risk of cerebral edema for each decrease of 7.8 mm Hg [representing 1 SD], 3.4; 95 percent confidence interval, 1.9 to 6.3; P<0.001) and higher initial serum urea nitrogen concentrations (relative risk of cerebral edema for each increase of 9 mg per deciliter [3.2 mmol per liter] [representing 1 SD], 1.7; 95 percent confidence interval, 1.2 to 2.5; P=0.003). A comparison of the children with cerebral edema with those in the matched control group also showed that cerebral edema was associated with lower partial pressures of arterial carbon dioxide and higher serum urea nitrogen concentrations. Of the therapeutic variables, only treatment with bicarbonate was associated with cerebral edema, after adjustment for other covariates (relative risk, 4.2; 95 percent confidence interval, 1.5 to 12.1; P=0.008).

CONCLUSIONS

Children with diabetic ketoacidosis who have low partial pressures of arterial carbon dioxide and high serum urea nitrogen concentrations at presentation and who are treated with bicarbonate are at increased risk for cerebral edema.

Antibiotic treatment of children with unsuspected meningococcal disease

BACKGROUND

Data from an earlier study suggest that patients with unsuspected meningococcal disease (UMD) cannot be differentiated easily from febrile children with viral syndromes on the basis of physical examinations or peripheral blood counts. Some children with meningococcal disease therefore are treated inadvertently as outpatients.

OBJECTIVE

To determine whether antibiotic therapy administered at the outpatient visit prevents complications, permanent sequelae, or death in children with UMD.

METHODS

We reviewed the medical records of patients younger than 20 years with invasive meningococcal disease at 7 pediatric referral centers from January 1, 1981, through December 31, 1996. Patients were considered to have UMD if they underwent evaluation and discharge as outpatients and if blood and/or cerebrospinal fluid cultures obtained at evaluation yielded Neisseria meningitidis. We compared the frequency of development of complications (meningitis, sepsis, and pericarditis), permanent sequelae (limb amputation, skin grafting, and persistent neurologic disability) or death between patients who did and did not receive antibiotics at the outpatient visits.

RESULTS

Of 58 children with UMD, 19 (33%) received antibiotics and 39 (67%) did not. Complications occurred significantly less frequently in the antibiotic-treated group (7/19 [37%] vs 27/39 [69%]; odds ratio [OR], 0.26; 95% confidence interval [CI], 0.08-0.81; P = .03). There was no significant difference in death or permanent sequelae between groups (0/19 vs 3/39 [8%]; OR, 0; 95% CI, 0-2.61; P=.54). There was insufficient power, however, to exclude the possibility of a clinically meaningful difference between the groups with regard to these latter outcomes.

CONCLUSIONS

Antibiotic administration to young patients with UMD at the time of the outpatient visit is associated with a reduction in complications from this disease. Although the routine use of antibiotics in febrile outpatients younger than 20 years cannot be advocated, empirical treatment should be considered in the setting of higher probability of meningococcal disease.

Isolated intraperitoneal fluid on abdominal computed tomography in children with blunt trauma

OBJECTIVE

To determine the frequency of isolated intraperitoneal fluid (IIF) on abdominal computed tomography (CT) in pediatric blunt trauma patients and the association between IIF and clinically identifiable intra-abdominal injuries (IAIs) in these patients.

METHODS

The authors conducted a prospective observational study of consecutive children <16 years old with blunt torso trauma who underwent abdominal CT scanning while in the emergency department (ED). All patients were evaluated by a faculty emergency physician who documented the patient's physical examination. All CTs were interpreted by a single faculty radiologist masked to clinical data. The volume of intraperitoneal fluid was quantified (small, moderate, large) and the presence of organ injury visible on CT was noted. Patients were considered to have IIF if the CT demonstrated intraperitoneal fluid and no solid organ injury. Patients with IIF were followed through their hospitalizations or telephoned in one week if discharged home from the ED.

RESULTS

Five hundred twenty-seven children with blunt trauma were enrolled into the study. The mean age (+/-SD) was 7.4 +/- 4.7 years, and the median pediatric trauma score was 10 (range -2 to 12). Eighty-eight patients (17%; 95% CI = 14% to 20%) had intraperitoneal fluid on CT scan and 42 (48%; 95% CI = 37% to 59%) of these patients had IIF. Of the 42 patients with IIF, five patients (all without abdominal tenderness and with a small amount of IIF on CT scan) were discharged to home from the ED and were well at telephone follow-up; the remaining 37 patients were hospitalized. Of the 42 patients with IIF, 7 patients (17%, 95% CI = 7 to 31%) had IAIs subsequently identified (all gastrointestinal injuries) during their evaluations. Six of the seven patients with IIF and subsequently identified IAIs had abdominal tenderness on examination in the ED. The remaining patient had a decreased level of consciousness.

CONCLUSIONS

Isolated intraperitoneal fluid occurs in 8% of pediatric blunt trauma patients undergoing abdominal CT, and IAIs are subsequently identified in 17% of these patients. Patients with a small amount of IIF on CT who lack abdominal tenderness and have a normal level of consciousness are at low risk for subsequently identified IAIs.

Predictors of intussusception in young children

OBJECTIVE

To identify predictors of intussusception in young children.

DESIGN

A retrospective cross-sectional study.

SETTING AND PATIENTS

A consecutive sample of children younger than 5 years on whom contrast enemas were performed because of suspected intussusception seen at an urban children's hospital from 1990 to 1995.

METHODS

We evaluated historical, clinical, and radiographic variables. Variables documented in 75% or more of the medical records and associated with intussusception (P< or =.20) in the univariate analysis were evaluated in a multiple logistic regression analysis. Variables retaining significance (P< or =.05) in the multivariate analysis were considered independent predictors of intussusception. We used bootstrap resampling techniques to validate the multivariate model.

RESULTS

Sixty-eight (59%) of the 115 patients had intussusception. Univariate predictors of intussusception included male sex, age younger than 2 years, history of emesis, rectal bleeding, lethargy, abdominal mass, and a highly suggestive abdominal radiograph. In the multivariate analysis, we identified only 4 independent predictors (adjusted odds ratio; 95% confidence interval): a highly suggestive abdominal radiograph (18.3; 4.0-83.1), rectal bleeding (17.3; 2.9-104.0), male sex (6.2; 1.2-32.3), and a history of emesis (13.4; 1.4-126.0). We identified 3 of these 4 variables (all but emesis) as independent predictors in more than 50% of 1000 bootstrap data samples.

CONCLUSIONS

Rectal bleeding, a highly suggestive abdominal radiograph, and male sex are variables independently associated with intussusception in a cohort of children suspected of having this diagnosis. Knowledge of these variables may assist in clinical decision making regarding diagnostic and therapeutic interventions.

Predictors of adverse events with intramuscular ketamine sedation in children

STUDY OBJECTIVE

Ketamine is a safe and effective sedative for emergency department procedures in children. However, the use of ketamine sometimes is associated with airway complications, emesis, and recovery agitation. We wished to identify predictors of these adverse events that clinicians might use to risk-stratify children who are candidates for ketamine sedation.

METHODS

We analyzed data from 1,021 ED intramuscular ketamine sedations in children 15 years of age or younger at a university medical center and an affiliated county hospital over a 9-year period. Five potential predictor variables (age, gender, American Society of Anesthesiologists' [ASA] risk classification, quantity of first ketamine dose, and number of ketamine doses administered) were compared between children with and without complications. We used multiple logistic regression analyses to determine the association of these 5 variables with emesis and recovery agitation, and validated these analyses with bootstrap resampling techniques. We compared children with and without airway complications using univariate statistics alone, as there were too few patients with airway complications to support a multivariate analysis.

RESULTS

No study variables had significant univariate associations with airway complications (all P values >.40). We found emesis to be associated with increasing age in multivariate analysis (odds ratio [OR] 1.25 per year, bias-corrected 95% confidence interval [CI] 1.17 to 1.34, P<.001). The incidence of emesis was 12. 1% in children aged 5 years or older, and 3.5% in those younger than 5 years (Delta8.6%, 95% CI 4.9% to 12.1%). Recovery agitation was associated with the presence of an underlying medical condition (ie, ASA class > or =2, OR 3.05, bias-corrected 95% CI 1.65 to 7.30, P=.004) and inversely associated with increasing age (OR 0.79 per year, bias-corrected 95% CI 0.69 to 0.89, P<.001). The incidence of recovery agitation was 17.9% in ASA class 1 children and 33.3% in children in ASA class 2 or greater (Delta-15.4%, 95% CI 0.0% to -30. 7%). The incidence of recovery agitation was 12.1% in children aged 5 years or older, and 22.5% in those younger than 5 years (Delta-10. 4%, 95% CI -3.0% to -17.7%). Bootstrap resampling techniques validated the importance of the significant variables identified in the regression analyses.

CONCLUSION

No study variable was predictive of ketamine-associated airway complications. Emesis that occurred after ketamine administration was modestly associated with increasing age. Recovery agitation was modestly associated with decreasing age and the presence of an underlying medical condition. The discriminatory power of these variables was low enough as to be unlikely to alter clinical decisions regarding patient selection for ketamine administration. No evidence of a significant ketamine dose relationship was noted for airway complications, emesis, or recovery agitation.

Occult bacteremia in young febrile children

The evaluation of nontoxic-appearing, young, febrile children has been a subject of considerable debate. Of young, nontoxic-appearing children aged 3 to 36 months with temperatures of 39 degrees C or more and no clear source, approximately 2% to 3% have occult bacteremia. Of these bacteremias, approximately 90% are caused by S. pneumoniae, 5% by nontyphoidal Salmonella sp., and 1% by N. meningitidis. Most children with occult pneumococcal bacteremia improve spontaneously, but approximately 25% of untreated patients have persistent bacteremia or develop new focal infections, including 3% to 6% who develop meningitis. Occult meningococcal bacteremia, although rare, has frequent complications, including meningitis in approximately 40% and death in approximately 4%. Less is known about the natural history of untreated occult nontyphoidal Salmonella bacteremia. Empiric antibiotic treatment of children with occult bacteremia decreases the rate of complications, including meningitis. Few disagree that febrile, young children at risk for occult bacteremia require a careful clinical evaluation and close follow-up. The benefits of laboratory screening and selective empiric antibiotic treatment of febrile children at risk for occult bacteremia have to be weighed against the costs of screening tests and blood cultures, inconvenience, temporary discomfort to patients, risk for side effects of antibiotics, and the role of antibiotics in the development of bacterial resistance. Although great debate exists concerning the role of empiric antibiotics, a strategy for obtaining blood cultures and empirically administering antibiotics on the basis of an increased ANC, in addition to close clinical follow-up, may be effective in reducing the frequency and severity of uncommon but adverse sequelae. A highly effective S. pneumoniae bacterial conjugate vaccine will soon be available, which will benefit all children, and will alter the ways that clinicians evaluate fully immunized young, febrile children.

Identification of intra-abdominal injuries in children hospitalized following blunt torso trauma

OBJECTIVE

To determine the utility of the ED physical examination and laboratory analysis in screening hospitalized pediatric blunt trauma patients for intra-abdominal injuries (IAIs).

METHODS

The authors reviewed the records of all patients aged <15 years who sustained blunt traumatic injury and were admitted to a Level 1 trauma center over a four-year period. Patients were considered high-risk for IAI if they had any of the following at ED presentation: decreased level of consciousness (GCS < 15), abdominal pain, tenderness on abdominal examination, or gross hematuria. Patients without any of these findings were considered moderate risk for LAI. The authors compared moderate-risk patients with and without IAIs with regard to physical examination and laboratory findings obtained in the ED.

RESULTS

Of 1,040 children with blunt trauma, 559 (54%) were high-risk and 481 (46%) were moderate-risk for IAI. 126 (23%) of the high-risk and 22 (4.6%) of the moderate-risk patients had IAIs. Among moderate-risk patients with and without IAIs, those with IAIs were more likely to have abdominal abrasions (5/22 vs 34/459, p = 0.008), an abnormal chest examination (11/22 vs 86/457, p = 0.01), higher mean serum concentrations of aspartate aminotransferase (AST) (604 U/L vs 77 U/L, p < 0.001) and alanine aminotransferase (ALT) (276 U/L vs 39 U/L, p = 0.002), higher mean white blood cell (WBC) counts (16.3 K/mm3 vs 12.8 K/mm3, p < 0.001), and a higher prevalence of >5 RBCs/hpf on urinalysis (7/22 vs 54/427, p = 0.02). There was no significant difference (p > 0.05) between moderate-risk patients with and without IAIs in initial serum concentrations of amylase, initial hematocrit, drop in hematocrit >5 percentage points in the ED, or initial serum bicarbonate concentrations.

CONCLUSION

In children hospitalized for blunt torso trauma who are at moderate risk for IAI, ED findings of abdominal abrasions, an abnormal chest examination, and microscopic hematuria as well as elevated levels of AST and ALT, and elevated WBC count are associated with IAI.

Immature neutrophils in the blood smears of young febrile children

OBJECTIVE

To determine whether the immature neutrophil (band) count in the peripheral blood smear helps to distinguish young febrile children with bacterial or respiratory viral infections.

DESIGN AND SETTING

A prospective cohort study in 3 pediatric emergency departments.

PATIENTS

A convenience sample of 100 febrile children aged 2 years or younger with either laboratory-documented bacterial infections (n = 31; 24 with urinary tract infections, 7 with bacteremia) or laboratory-documented respiratory viral infections (n = 69). Each patient received a clinical appearance score using the Yale Observation Scale prior to laboratory evaluation. A complete blood cell count was obtained from all patients and manual differential count of the peripheral blood smear was performed by 1 senior technician masked to clinical information.

MAIN OUTCOME MEASURE

Band counts, represented as a percentage of white blood cells in the peripheral blood smear, the absolute band count, and band-neutrophil ratio. Logistic regression analysis was performed to determine whether the band count helps to distinguish bacterial infections from viral infections after adjusting for age, temperature, Yale Observation Scale score, and absolute neutrophil count.

RESULTS

Patients with bacterial infections had a higher mean absolute neutrophil count (11.3 vs 5.9 x 10(9)/L; P<.01) than patients with respiratory viral infections. There was no difference, however, in percentage band count (13.5% vs 13.3%; P = .90), absolute band count (2.2 vs 1.9 X 10(9)/L; P= .31), or band-neutrophil ratio (0.24 vs 0.33; P = .08, bacterial vs viral, respectively); the band count did not help to distinguish bacterial and viral infections after adjusting for age, temperature, Yale Observation Scale score, and absolute neutrophil count in the regression analysis.

CONCLUSION

The band count in the peripheral blood smear does not routinely help to distinguish bacterial infections from respiratory viral infections in young febrile children.

Clinical and hematologic features do not reliably identify children with unsuspected meningococcal disease

OBJECTIVE

To determine the frequency of unsuspected meningococcal disease (UMD) in young febrile children with meningococcal infections and evaluate whether clinical and laboratory parameters commonly used in the evaluation of fever can help identify children with UMD.

METHODS

We reviewed the records of children with meningococcal disease from 1985 to 1996 at four referral centers. Children who were evaluated as outpatients and then discharged to home, from whom Neisseria meningitidis was isolated from blood or cerebrospinal fluid cultures obtained during these outpatient visits, were considered to have UMD. We compared clinical and laboratory parameters between these children and 6414 febrile outpatients 3 to 36 months old with negative blood cultures enrolled in a separate study of occult bacteremia.

RESULTS

We identified 381 children with meningococcal disease, of whom 45 (12%) had UMD. Of the 45 with UMD, 37 (82%) were 3 to 36 months old. Compared with the 6414 culture-negative patients, these 37 patients with UMD were significantly younger (8.9 +/- 5.4 vs 14.2 +/- 8.1 months) and had significantly higher band counts (14.3 +/- 11.1 vs 7.3 +/- 7.5%). There were no significant differences, however, in temperature, white blood cell counts, and absolute neutrophil counts. Multivariate analysis identified young age and the band count as independent predictors of UMD.

CONCLUSIONS

Children ultimately diagnosed with meningococcal disease have commonly been evaluated as outpatients and discharged to home before diagnosis. Of the hematologic parameters frequently used in the evaluation of fever, only the band count differs significantly between young febrile children with UMD and those with negative cultures. Because UMD is uncommon in young febrile pediatric outpatients, however, the predictive value of the band count is low. Thus, the complete blood count is not routinely helpful for the diagnosis of UMD.

Evaluation of febrile children with petechial rashes: is there consensus among pediatricians?

BACKGROUND

The evaluation of febrile children with petechial rashes evokes controversy. Although many of these children have viral infections, on occasion such patients may be infected with Neisseria meningitidis.

OBJECTIVE

To investigate differences in practice trends for the evaluation and management of non-toxic-appearing febrile children with petechial rashes among pediatric specialty groups.

METHODS

We surveyed 833 pediatricians in 4 specialties [community (CGP) and academic (AGP) general pediatrics, emergency medicine (EM) and infectious diseases] regarding 4 hypothetical non-toxic-appearing febrile children ages 1, 2, 5 and 7 years. The patients differed with regard to clinical appearance, distribution of petechiae and complete blood count results. We compared specialty group responses, adjusting for practice setting, population size and years in practice using multiple logistic regression analysis.

RESULTS

The survey was completed and returned by 416 (50%) pediatricians. There was substantial variation in the evaluation of the 2 younger febrile children without clear sources for their petechiae. For the 1-year-old the overall blood culture (BCx) rate was 82%, with the EM group (91%) more often requesting BCx than either the CGP (76%) or AGP (73%, P=0.001) groups. The overall hospital admission rate was 31%, with CGP less often requesting admission than infectious disease pediatricians (22% vs. 40%, P=0.007). In the regression analysis the only significant difference between groups was in BCx rate between the EM and AGP groups. For the 2-year-old the overall rate of BCx was 95%, lumbar puncture was 41% and admission was 44%, with no significant differences among groups. For the scenarios involving the 2 older febrile children with sources for their petechiae, the majority of respondents chose neither lumbar puncture nor admission. There was disagreement regarding BCx, both within and between groups, although most of the between group differences did not persist in the regression analysis.

CONCLUSIONS

There are substantial differences among pediatricians in the evaluation of young non-toxic-appearing febrile children with petechial rashes. Although there are some differences between pediatric subspecialties, most of these differences do not persist after adjusting for practice setting, population size and physician experience.

Cerebrospinal fluid pleocytosis and prognosis in invasive meningococcal disease in children

BACKGROUND

The absence of cerebrospinal fluid (CSF) pleocytosis in invasive meningococcal disease (IMD) has been associated with an increased risk of death. It is unknown whether patients who lack a cellular response to central nervous system (CNS) infection are at the same risk of adverse outcome as patients who lack CNS infection.

OBJECTIVES

To determine the frequency of presentation and outcome of three groups of children with IMD: Group 1, children with CSF pleocytosis; Group 2, children without CSF pleocytosis and with negative CSF cultures (bacteremia alone); and Group 3, children without CSF pleocytosis but with positive CSF cultures (CNS infection without CSF pleocytosis).

METHODS

We reviewed the medical records of children with IMD at four pediatric referral hospitals between 1985 and 1996. Clinical and laboratory indices and severe adverse outcomes (defined as death or limb loss) were compared in the three groups. Multivariable logistic regression analysis was performed to determine whether CNS infection without CSF pleocytosis was independently associated with adverse outcome in IMD.

RESULTS

Three hundred seventy-seven children with IMD were identified. Eighty-six patients were excluded because their CSF analysis either was not done or was unevaluable; of these patients 22 (25.6%) had an adverse outcome. Of the 291 evaluable patients 204 (70.1%) had CSF pleocytosis, 52 (17.9%) had bacteremia alone and 35 (12.0%) had CNS infection without CSF pleocytosis. Patients with CNS infection without CSF pleocytosis had significantly lower white blood cell and platelet counts and more coagulopathy than patients with bacteremia alone (P < or = 0.05) or patients with CSF pleocytosis (P < or = 0.01). The frequency of adverse outcome was 40% for patients with CNS infection without CSF pleocytosis compared with 9.6% for patients with bacteremia alone (P = 0.001) and 3.4% for patients with CSF pleocytosis (P < 0.001). CNS infection without CSF pleocytosis was independently associated with adverse outcome by multivariable logistic regression analysis (P = 0.003).

CONCLUSIONS

Approximately 30% of all children with IMD present without CSF pleocytosis. Of these patients those with CNS infection without pleocytosis are at higher risk of adverse outcome than either patients with CSF pleocytosis or patients with bacteremia alone.

Predictors of occult pneumococcal bacteremia in young febrile children

STUDY OBJECTIVE

Occult pneumococcal bacteremia (OPB) occurs in 2.5% to 3% of highly febrile children 3 to 36 months of age, and 10% to 25% of untreated patients with OPB experience complications, including 3% to 6% in whom meningitis develops. The purpose of this study was to identify predictors of OPB among a large cohort of young, febrile children treated as outpatients using multivariable statistical methods.

METHODS

We derived and validated a logistic regression model for the prediction of OPB. We evaluated 6,579 outpatients 3 to 36 months of age with temperatures of 39 degrees C or higher who previously had been enrolled in a study of young febrile patients at risk of OPB in the emergency departments of 10 hospitals in the United States between 1987 and 1991; 164 patients (2.5%) had OPB. We randomly selected two thirds of this population for the derivation of the model and one third for validation. In the derivation set, we analyzed the univariate relationships of six variables with OPB: age, temperature, clinical score, WBC count, absolute neutrophil count (ANC), and absolute band count (ABC). All six variables were then entered into a logistic regression equation and those retaining statistical significance were considered to have an independent association with OPB.

RESULTS

Patients with OPB were younger, more frequently ill-appearing, and had higher temperatures, WBC, ANC, and ABC than patients without bacteremia. Only three variables, however, retained statistically significant associations with OPB in the multivariate analysis: ANC (Adjusted odds ratio [OR] 1.15 for each 1,000 cells/mm3 increase, 95% confidence interval [CI] 1.06, 1.25), temperature (adjusted OR 1.77 for each 1 degree C increase, 95% CI 1.21, 2.58), and age younger than 2 years (adjusted OR 2.43 versus patients 2 to 3 years old, 95% CI interval 1.11, 5.34). In the derivation set, 8.1% of patients with ANCs greater than or equal to 10,000 cell/mm3 had OPB (95% CI 6.3, 10.1%) versus .8% of patients with ANCs less than 10,000 cells/mm3 (95% CI .5, 1.2%). When tested on the validation set, the model performed similarly.

CONCLUSION

Independent predictors of OPB in children 3 to 36 months of age with temperatures of 39 degrees C or higher treated as outpatients include ANC, temperature, and age younger than 2 years. These predictors may be used to develop clinical strategies to limit laboratory testing and antibiotic administration to those children at greatest risk of OPB.

Risks for bacteremia and urinary tract infections in young febrile children with bronchiolitis

OBJECTIVE

To compare the risks for bacteremia and urinary tract injections (UTI) in young febrile children with and without bronchiolitis.

DESIGN

A prospective cohort study.

SETTING

The emergency departments of 3 pediatric referral hospitals.

PATIENTS

A convenience sample of 432 previously healthy febrile patients aged 24 months or younger. Patients were divided into groups, based on the presence (n = 163, bronchiolitis group) or absence (n = 269, control group) of wheezing and/or retractions on examination. Blood cultures were obtained from all patients, and urine cultures were obtained from female patients, and male patients aged 6 months or younger. Chest radiographs were obtained on patients with lower respiratory tract signs, and those with lobar pneumonias were excluded (7 wheezing and 8 nonwheezing patients), leaving 156 patients with bronchiolitis and 261 control patients.

OUTCOME MEASURES

Growth of any bacterial pathogens from the blood or 10(4) colony-forming units per milliliter or more from the urine.

RESULTS

None of the 156 patients with bronchiolitis had bacteremia (95% confidence interval, 0%-1.9%) vs 2.7% of the 261 controls (95% confidence interval, 1.1%-5.4%; P = .049); 1.9% of the patients with bronchiolitis had UTI vs 13.6% of the controls (odds ratio, 0.12; 95% confidence interval, 0.02-0.55; P = .001). None of the subset of patients with bronchiolitis aged 2 months or younger (n = 36) had bacteremia or UTI; however, there were not enough of these younger patients to make statistically conclusive comparisons.

CONCLUSIONS

Previously healthy febrile children aged 24 months or younger with bronchiolitis are unlikely to have bacteremia or UTI. Therefore, routine cultures of the blood and urine in these patients are unnecessary. More data are needed regarding the subset of febrile infants aged 2 months or younger with bronchiolitis.

Variation in the management of pediatric diabetic ketoacidosis by specialty training

OBJECTIVE

To compare management strategies for pediatric diabetic ketoacidosis (DKA) among physicians with different specialty training.

METHODS

We conducted a mail survey of 1000 randomly selected physicians, including 200 pediatric endocrinologists, 200 general emergency physicians, 200 pediatric emergency physicians, 200 pediatric intensivists, and 200 pediatric chief residents. We posed questions regarding a hypothetical 10-year-old patient with new onset of diabetes mellitus who is approximately 10% dehydrated but alert, with venous pH of 7.1 and serum glucose concentration of 34.7 mmol/L (625 mg/dL). Questions involved the rate of rehydration, content of intravenous fluids, insulin therapy, potassium replacement, use of sodium bicarbonate, and adjustments in therapy for decreasing serum glucose concentration. We compared responses of physicians in each specialty and used multiple regression analysis to adjust for potential confounding variables, including number of years in practice, number of children with DKA seen per month, and practice setting.

RESULTS

Five hundred eighty-one physicians (58.1%) completed the survey, with responses demonstrating significant, consistent differences between specialties. Extremes of responses included the following: (1) 59% of endocrinologists vs 11% of general emergency physicians would give an initial fluid bolus of less than 20 mL/kg (odds ratio [OR], 11.7; 95% confidence interval [CI], 5.0-27.7) (P < .001); (2) 83.5% of general emergency physicians vs 42.5% of pediatric intensivists would administer an initial insulin bolus (OR, 4.1; 95% CI, 2.0-8.7) (P < .001); (3) 58.2% of pediatric intensivists vs 9% of general emergency physicians would replace fluids over a period of greater than 24 hours (OR, 14.1; 95% CI, 5.5-37.5) (P < .001); and (4) 54.3% of general emergency physicians vs 7.3% of pediatric intensivists would use potassium chloride alone for potassium replacement (OR, 10.8; 95% CI, 5.0-23.8) (P < .001). All of these differences persisted after adjusting for the potential confounding variables.

CONCLUSIONS

Substantial differences exist in the management of pediatric DKA among physicians of different specialties, presumably due to differences in specialty training. These differences obscure our ability to evaluate the treatment of DKA and highlight the necessity for further studies comparing the outcomes of different treatment strategies.

Atypical presentation of Henoch-Schoenlein purpura in two children

Henoch-Schoenlein purpura (HSP) is a common vasculitic disorder of childhood. Patients with this disorder typically present with palpable purpura or petechia associated with one or more of the following signs and symptoms: abdominal pain, arthritis/arthralgias, and nephritis. The diagnosis may be difficult to make, however, when a patient presents with isolated symptoms such as abdominal pain without the typical rash. A high index of suspicion must be maintained to diagnose HSP in this setting and to avoid unnecessary interventions. This report describes two unusual patients with the presenting complaint of abdominal pain who had delayed onset of the purpuric rash, making the diagnosis of HSP difficult.

Diagnostic testing for acute head injury in children: when are head computed tomography and skull radiographs indicated?

OBJECTIVE

Despite the frequent occurrence of head injury in children, there is no agreement about clinical screening criteria that indicate the need for imaging studies. This study was undertaken to provide information relevant to the choice of imaging modalities in children with acute head trauma.

METHODOLOGY

A prospective cohort of 322 children seeking care consecutively in an urban pediatric emergency department for nontrivial head injury was assembled. Skull radiographs, head computed tomography, and data forms including mechanism of injury, symptoms, and physical findings were completed for each child.

RESULTS

Intracranial injury occurred in 27 children (8%), whereas 50 (16%) had skull fractures. Of those with intracranial injury, 16 (59%) had normal mental status and no focal abnormalities, and 1 of those 16 required surgery for evacuation of an epidural hematoma. Six (38%) of the 16 were younger than 1 year, 5 of whom had scalp contusion or hematoma without other symptoms. Findings not significantly associated with intracranial injury were scalp contusion, laceration, hematoma, abrasion, headache, vomiting, seizure, drowsiness, amnesia, and loss of consciousness for less than 5 minutes. Findings associated with intracranial injury were skull fracture, signs of a basilar skull fracture, loss of consciousness for more than 5 minutes, altered mental status, and focal neurologic abnormality.

CONCLUSIONS

Intracranial injury may occur with few or subtle signs and symptoms, especially in infants younger than 1 year. The relative risk for intracranial injury is increased almost fourfold in the presence of a skull fracture, although the absence of a skull fracture does not rule out intracranial injury. The significance of nonsurgical intracranial injury in neurologically normal children needs further study.

Intravenous versus oral corticosteroids in the management of acute asthma in children

STUDY OBJECTIVE

To determine whether oral corticosteroids are significantly better at preventing the need for hospital admission than i.v. corticosteroids in children with moderate to severe asthma exacerbation.

METHODS

We carried out a randomized, double-blind, controlled trial of patients in the emergency department of a tertiary urban children's hospital. Patients who presented to the ED with moderate to severe asthma (defined as forced expiratory volume in 1 second [FEV1] < 60% predicted for height in patients aged 7 to 18 years and as Pulmonary Index Score [PIS] between 6 and 11 for patients aged 18 months through 6 years). Patients were randomized to receive 2 mg/kg oral methylprednisolone or 2 mg/kg i.v. methylprednisolone 30 minutes after the initial treatment with nebulized albuterol. Each patient was otherwise treated with an identical regimen of frequent nebulized albuterol and i.v. theophylline for a total of 4 hours.

RESULTS

Forty-nine patients were enrolled. Four hours after treatment, both groups had similar respiratory rates, oxygen saturation, PISs, and FEV1 values. Eleven of 23 patients in the oral group (48%) and 13 of 26 patients in the i.v group (50%) were admitted to the hospital (P = .88). The 90% confidence interval for the 2% cifference in admission rate to the hospital (favoring oral methylprednisolone) ranged from 21% (favoring i.v. methylpredinisolone) to 25% (favoring oral methylprednisolone). Patients discharged home demonstrated greater improvement from baseline with regard to PIS and FEV1 than patients who were admitted. Two patients in each group failed to complete the standard treatment or returned to the hospital within 48 hours of ED discharge.

CONCLUSION

These data suggest that for children with moderate to severe asthma exacerbation, hospital admission rates are similar in children given oral methylprednisolone and those given i.v. methylprednisolone.

Multivariable predictive models for adverse outcome of invasive meningococcal disease in children

For prediction of adverse outcome (AO, defined as death or limb amputation) of invasive meningococcal disease (IMD) in children, two multivariable models were derived and validated by reviewing the data in the medical records of patients with IMD, who ranged from birth to 19 years of age, at three pediatric referral hospitals between 1985 and 1990 (derivation set, n = 153, 19 AO) and between 1991 and 1994 (validation set, n = 92, 11 AO). Variables in the derivation set significantly associated with AO (p < 0.05) were entered into a logistic regression analysis. Because coagulation studies (prothrombin time, partial thromboplastin time, and serum fibrinogen concentration) were available for only 50% of patients, two analyses were performed, either excluding (model 1) or including (model 2) coagulation studies. These analyses identified an absolute neutrophil count less than 3000/mm3, poor perfusion, and a platelet count less than 150,000/mm3 (model 1), and a serum fibrinogen concentration less than 2.5 gm/L (250 mg/dl) and an absolute neutrophil count less than 3000/mm3 (model 2), as independent predictors of AO (p < 0.05). When the models were tested on the validation set, the presence of at least two of the three predictors in model 1 had a sensitivity of 82% and a specificity of 97% in predicting AO; the presence of both predictors in model 2 had a sensitivity of 89% and a specificity of 97%. These models can reliably identify patients with IMD at high risk of AO for whom consideration of novel therapies is justified.

Comparison of early and late treatment with a recombinant endotoxin neutralizing protein in a rat model of Escherichia coli sepsis

OBJECTIVE

To test the efficacy of a recombinant endotoxin neutralizing protein as compared with saline in rats with Escherichia coli sepsis.

DESIGN

Prospective, controlled animal trial.

SETTING

Hospital animal research laboratory.

SUBJECTS

Male Wistar rats challenged with intraperitoneal E. coli, O18ac K1, and treated 1 hr later with ceftriaxone and gentamicin.

INTERVENTIONS

Recombinant endotoxin neutralizing protein, 50 mg/kg, was administered to rats 1, 2, or 3 hrs after E. coli challenge; saline was administered to control animals.

MEASUREMENTS AND MAIN RESULTS

Quantitative bacteremia, 1 hr after challenge and before antibiotic administration, was not significantly different between treatment groups (range geometric mean 451 to 621 colony-forming units [cfu]/mL). The endotoxin concentration, measured immediately before recombinant endotoxin neutralizing protein administration, was significantly higher in animals sampled and treated at 2 hrs (geometric mean 260 EU/mL; 95% confidence interval 140 to 480 EU/mL), or 3 hrs (geometric mean 697 EU/mL; 95% confidence interval 307 to 1585 EU/mL) after E. coli challenge, compared with animals sampled and treated at 1 hr (geometric mean 17 EU/mL; 95% confidence interval 7 to 69 EU/ mL). Survival rate was significantly greater in rats treated with recombinant endotoxin neutralizing protein at 1 hr (23/27; p < .001) or 2 hrs (8/30; p < .01) after E. coli challenge than in controls (1/32).

CONCLUSION

Administration of recombinant endotoxin neutralizing protein delayed up to 2 hrs after challenge with E. coli improves survival in antibiotic-treated rats with Gram-negative sepsis.

Perforation of the colon in an adolescent girl

We report a case of a 13-year-old girl who presented with acute abdominal pain secondary to a sigmoid colon perforation. History, physical examination, and laboratory and radiographic studies were all suggestive, though not diagnostic, of an abdominal catastrophe. Her father died at the age of 30 from complications of bowel perforations and a vascular aneurysm. The unusual operative findings in our patient, together with her father's medical history, lead to the underlying diagnosis of Ehlers-Danlos syndrome. Knowledge of this family history at the time of presentation could have aided in diagnosis. Clinical manifestations and etiology of Ehlers-Danlos syndrome are discussed.

Recombinant endotoxin neutralizing protein improves survival from Escherichia coli sepsis in rats

OBJECTIVE

A recombinant endotoxin neutralizing protein was evaluated for its ability to ameliorate the effects of Escherichia coli sepsis in rats.

DESIGN

Prospective, controlled animal trial.

SETTING

Hospital animal research laboratory.

SUBJECTS

Wistar rats, treated with gentamicin 1 hr after challenge with intraperitoneal E. coli O18ac.

INTERVENTIONS

The animals received a recombinant endotoxin neutralizing protein, in doses of 5, 25, or 50 mg/kg, either 30 or 60 mins after challenge; controls received saline.

MEASUREMENTS AND MAIN RESULTS

Geometric mean serum endotoxin concentrations in endotoxin neutralizing protein-treated animals did not differ from control animals. Tumor necrosis factor concentrations in animals treated with endotoxin neutralizing protein 30 mins after challenge were significantly lower than controls. Animals treated with 25 or 50 mg/kg of endotoxin neutralizing protein 30 mins after E. coli challenge had significant improvements in survival compared with controls. Animals treated with 50 mg/kg of endotoxin neutralizing protein 60 mins after E. coli challenge had significant improvements in survival compared with controls.

CONCLUSION

Endotoxin neutralizing protein significantly reduces mortality from Gram-negative sepsis in an antibiotic-treatment model of E. coli peritonitis and bacteremia in rats, mediated by a neutralization of the biological effects of endotoxin.

The role of heparin in the prevention of extremity and digit necrosis in meningococcal purpura fulminans

In order to gather data regarding the utility of heparin therapy in limiting digit and extremity necrosis resulting from meningococcal purpura fulminans in children, we reviewed the charts of 24 pediatric patients with PF associated with meningococcal disease. Our study population was comprised of the 13 patients who survived more than 2 days. Clinical and outcome data were compared between the group of patients who received therapeutic heparin treatment in the initial 72 hours (> or = 50 units/kg bolus followed by an infusion, three patients) and the group who did not (10 patients). Demographic and initial clinical and laboratory findings were similar between groups (P > 0.15). When the two groups were compared for dermatologic and orthopedic sequelae, the mean number of digits (6.3 vs. 11.1; P = 0.35) and extremities (1.7 vs. 3.0; P = 0.17) with necrosis was less in those patients who received therapeutic doses of heparin, although the differences were not statistically significant. When only those patients on whom diffuse purpura were noted on admission were compared, these differences were greater. This small, retrospective series suggests that heparin therapy may limit digit and extremity necrosis when used early and in therapeutic doses in meningococcal purpura fulminans. Therefore, a larger, prospective controlled trial is warranted.

Comparison of a recombinant endotoxin-neutralizing protein with a human monoclonal antibody to endotoxin for the treatment of Escherichia coli sepsis in rats

A recombinant endotoxin-neutralizing protein (ENP) from Limulus polyphemus and a monoclonal IgM anti-lipid A antibody (HA-1A) were compared in a rat model of Escherichia coli sepsis. One hour after intraperitoneal challenge with 10(6) cfu of E. coli O18ac K1, animals were sensitized to endotoxin with lead acetate and treated with ENP, HA-1A, or saline, followed by ceftriaxone and gentamicin. Before treatment, 95% of rats had high-grade bacteremia and high serum endotoxin concentrations, which were similar in all treatment groups (P > .60). One hour after treatment, there was no bacterial growth in any blood sample, and endotoxin concentrations were significantly lower in the ENP group than in the HA-1A and saline groups (P < .01). At 24 h after challenge, survival in the ENP group was significantly higher than in the HA-1A saline group (P < .001). ENP improved survival in a rat model of E. coli sepsis with high mortality despite effective antibiotic therapy.

Serious sports injuries requiring hospitalization seen in a pediatric emergency department

OBJECTIVE

To define the spectrum of serious sports injuries requiring hospitalization seen in a pediatric emergency department.

DESIGN

Trauma registry and retrospective chart reviews.

SETTING

Emergency department, Children's Hospital, Boston, Mass.

STUDY PARTICIPANTS

One hundred forty-two patients with sports injuries presenting to the emergency department and requiring hospitalization over 2 years.

MEASUREMENTS/RESULTS

Serious sports injuries accounted for 13% of admissions for trauma, 0.6% of visits to the emergency department for trauma, and approximately 0.14% of total encounters. Injuries included fractures (77%), abdominal injuries (7%), multiple trauma (5%), cerebral contusions or hemorrhages (4%), and dislocations (3%). The most frequently injured areas were the extremities (69%), head and neck (16%), and abdomen (3%). Compared with nonsports injuries requiring hospitalization, sports injuries occurred in older patients (11.5 vs 7.3 years, P < .001) and more often in males (83% vs 64%, P < .001). Sports injuries also resulted in higher Injury Severity Scores (10 vs 8.8, P = .021) and in more fractures (77% vs 51%, P < .001) and neck injuries (4% vs 1%, P = .002).

CONCLUSION

Serious sports injuries evaluated in the emergency department affect predominantly male teenagers and result predominantly in fractures involving the extremities. The spectrum of injuries is dissimilar to that resulting from other mechanisms.

Transient infantile hypertension

Images